Healthcare Provider Details

I. General information

NPI: 1528453768
Provider Name (Legal Business Name): BASILISA SURGICAL ASSISTANT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2015
Last Update Date: 04/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25200 INTERSTATE 45 APT 104
SPRING TX
77386-1414
US

IV. Provider business mailing address

330 RAYFORD RD STE 238
SPRING TX
77386-1980
US

V. Phone/Fax

Practice location:
  • Phone: 832-908-7831
  • Fax:
Mailing address:
  • Phone: 832-908-7831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: MANUEL SALVADOR LOPEZ CARDENAS
Title or Position: OWNER
Credential:
Phone: 832-908-7831